R 4978 PERMIT R_ 497
8
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS /J
/ISy ECM 5 Foi D D2 RESIDENTIAL—X—COMMERCIAL OTHER
OWNER'S r HAZARDOUS FIRE AREA
J N lf`J YES ❑ If yes—I understand that a Class A
�I/�1 / /G
NAME J?C. V G roof assembly is required.
IY �1 NO Initial I.C.B.O.a
'ADDRESS 10 60( H4-be-to � EXISTING ROOF COVERING
''7(/K -
PHONE D / !-�/ /6 D NUMBER OF EXISTING COVERINGS I
CONTRACT'
R'(�
NAME
J �Gl� CON�TIP(ICTip TOBEREMOVED__J__TOBERETAINED�
ADDRESS /OGDI M, TYPE
V� C FSZ �PEOFROOF COVERING
CITU&ZIP sg ^� EXISTING
PHONE �/riap / �C. - BUILT-UP ROOF ❑
LICENSE ❑ j/
NUMBER D6 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm Ihel I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES G �i
7000)of Divlalon 3 of the Business and Professions Code,and my license Is In full force antl
effect.
WOOD SHINGLES ❑
License Class Llc.Number 7 IG
Date 9.2 Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby Hlrm that I em exempt from the Conlmctors License Lew for the following reason.
(Sac7031.5,Business and Professions Code: Any city or county which requires a permit to
coneiruct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP RO � ❑
applicant for such permit to file a elgned statement that he Is licensed Pursuant to the provisions 9
of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the nr.
Business and Professions Code)or that he to exempt therefrom and the basis for the alleged ASPHALT'SHINGLES
exemption.Any violation of Section 7031.$by any applicant for a Permit subjects the applicant to vi-
`f a civil penalty of not more than five hundred dollars($500).): (,Lr-
0 1,
,Lr-❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ��f ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles-
Bions Code: The Contractor's License Lew does not apply to an owner of property who bullds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such pmIsols
with a contractor(e)licensed pursuant to the Contractor's License Law.
❑I am exempt untler 9e ,B 8 P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner— Date APPLICATION DATE VALUATION PERMIT FEE
WORKEP rf. �MPENSATION DECLARATION
t I herab firm under penalty of rjury one of the following declaration;
❑I h antl will maintain a Certificate of Concent to self-insure for Workers Compensation, e1 vo-
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /2�/�� Building
permit la Issued. $eISR11C , n
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 0l
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers ODO Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not de completed If the permit Is for one hundred dollars($100)or lees.) 4�'1
I certify that In the performance of the work for which this permit Is Issued,I shall not employ f�
any person In any manner so as to become subject to the Workers'Cpeneellon L a of can. - All roofs Shall be inspected prior to any r ofing mate ial being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT) TO AP ?CAN : it
char making th erlificate of Exemption,you uld become Applicant understands and will comply with all non Dint
subject to the Workers'Compensation pravlel 1 the Labor Code,you mu rlhwith comply pP p y p
with such provisions or this permit she be ed revoked. SOUTCe regulations.
I certify that I have reed this application state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof ova 'ngs to be class"C" r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, Z
lutlgmenla,costa and expenses which may In any way accrue against said CITY In consequence
of the granting of this permit. SIGN OF APPLICAN ATE
PRE-INSPECTION: PLYWOOD: IN-PROGR S:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY